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everett <br />e <br />City of E•ierett <br />Engineering Department <br />Sewer Application and Permit <br />�- <br />NO. r_ . DATE <br />Service Address / <br />Billing nddress <br />City, State, Zip <br />Owner (Mortyagor) <br />Billing Name <br />Connection By_ <br />DESCRIPTION: <br />�ot _. r � � _ �C. <br />Bloc;< <br />Division or Addition _ <br />I� <br />� —�; <br />�.,e, _3�— ��- ;, <br />, /, <br />/'' ' <br />Utility Account Na.. <br />Connection Permit F <br />Connection Fee__ <br />Total Fee <br />3 <br />Sewer District <br />� <br />Monthly Sewer Service <br />Monthly Sewer Constr. <br />SEESKETCH ATTACHED <br />Lateral <br />4butting Lot Line <br />N, S, E, W <br />4pproved By <br />City Engineer <br />ssued <br />Irspection By � ^� <br />// <br />)ate Inspected %'"'-7� ��� <br />No. ?11_7°� <br />